MENTAL HEALTH CRISIS BEDS IN THE CITY OF OTTAWA: A Review and Roadmap for the Future

Transcription

1 MENTAL HEALTH CRISIS BEDS IN THE CITY OF OTTAWA: A Review and Roadmap for the Future Final Report September 2014

2 Table of Contents Executive Summary... 4 Project Background... 7 History of the Crisis Bed Program... 7 Review Activities... 7 Review Process... 8 Context... 8 Making It Happen... 8 The Champlain District Crisis System... 9 Mental Health Crisis Line (Tier I)... 9 Local Mobile Crisis Teams (Tier II) Crisis Beds The Ottawa Hospital Crisis Bed Program System Context Deinstitutionalization and Hospital Diversion Current approaches in crisis bed provision in Champlain Challenges and Opportunities: Ottawa Crisis Bed Program Admission and Exclusion Criteria Location issues People with mental health and addictions issues Medication supply, administration, and supervision Length of Stay Linkages and Partnerships Capacity and Utilization A broader paradigm shift Outcome Indicators and Target Standards Roadmap for Implementation and Proposed Timelines Bibliography Appendix A: Using Better Practice to Guide Next Steps Appendix B: Physical Location(s) Criteria for Consideration... 40

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4 Executive Summary The Ottawa Hospital has undertaken this review of its mental health crisis bed program (part of the Mobile Crisis Team) to identify: The level of satisfaction with the current program from the perspective of clients and family members, Opportunities to enhance the program from the perspective of better practices, How the crisis beds are currently operating within Ottawa, but also more broadly across the Champlain region, Key challenges and areas for improvement, and a short-, medium- and long-term set of recommendations for evolving the program. To this end, focus groups were held with clients and families, the Ottawa Mobile Crisis Team was consulted, other crisis bed providers within the region were interviewed, and a scan of other crisis bed programs was conducted. Overarching findings include: Clients and family members consulted are satisfied with the service and, in particular, spoke highly of crisis team staff, however, they reflected on the physical locations of the beds in an often negative way with respect to comfort, safety, and whether the environments of the current crisis beds was the best fit this is consistent feedback with mobile crisis team members Regionally, a key area of concern for all crisis bed providers is the fit of the model for youth and young adults from a safety and supervision perspective, but also in relation to challenges faced in addressing the needs of transition-aged youth and engaging them in appropriate services to facilitate timely discharge, Additional work is needed to better reflect an inclusive set of admission criteria or operating procedures relating to who should be admitted to the crisis beds: the reality that there are very few resources available for respite and the current set of admission criteria for the crisis beds seriously impact the system s ability to proactively work to avert a full-blown crisis. There are capacity issues, as well as issues related to target length of stay, across the region, The current number of physical sites used for the crisis beds in the City of Ottawa is too many, and creates inefficiencies related to staff travel time, The crisis bed program requires greater integration with key partners in the youth sector, addictions sector, and housing sector. Key recommendations are as follows: Regional Collaboration: Crisis Bed Objectives, Admission Criteria, Capacity and Evaluation That crisis bed providers incorporate specific objectives relating to crisis bed provision across the region, including identifying opportunities for consistency in inclusion criteria, regional reporting on utilization and issues, and ongoing identification of capacity issues and needs. That crisis bed providers use existing collaboration mechanisms for the regional crisis line and crisis teams to articulate common standards, guidelines or procedures for crisis beds across Champlain, including target length of stay, utilization of peer support, medication management, regional tracking of bed utilization and access processes, and other issues as identified In the context of a broader discussion with crisis bed partners, that current inclusion and exclusion criteria be reviewed and updated to reflect the following considerations and current practices, at a minimum 4 The Ottawa Hospital Crisis Bed Program Program Review September 2014

5 o That clients presenting in emergency or through Mental Health Court be considered high priority for admission to a crisis bed, o That ability to administer their own medications be removed from the inclusion criteria, o That willingness to abstain from substance use be removed from the inclusion criteria, o That a significant history of violent or assaultive behaviour be removed from the exclusion criteria o That exclusion criteria remove reference to developmental delay and housing-related crises This type of revision to inclusion and exclusion criteria needs to reflect more on behaviour and capacity related issues of the person. That the target length of stay for crisis beds be articulated in collaboration with other crisis bed providers within the Champlain LHIN, and in collaboration with LHIN staff That TOH and the Champlain LHIN explore capacity-related issues of the crisis bed program and that mobile crisis teams across Champlain engage in a discussion about needs and capacity issues of mobile crisis teams. Enhancing Partnerships: Emergency Services, Developmental Services, Addictions Services, and Youth Services That emergency department staff receive training on inclusion/exclusion criteria and procedures are developed to articulate the referral process when a client presents at the emergency department. That TOH engage with leaders in the dual diagnosis (mental health and developmental delay) field to outline a process that best meets the needs of people who are experiencing a mental health crisis, but also having varying degrees of developmental disabilities. That TOH engage with Withdrawal Management Services to effect a priority system for people presenting to the Emergency Room requiring WMS so as to ensure that these clients are not streamed to a crisis bed at an inappropriate time in their individual process. This engagement should include representation from the Champlain LHIN and should consider the following: priority access, communications among key partners (hospital emergency staff, OMCT and WMS staff), and collaborative treatment planning for people requiring and desiring both withdrawal management and crisis services. That the Mobile Crisis Team prepare a present a report on current issues with respect to housing and support options of crisis bed clients to : o Supportive Housing Network of Ottawa o Social Housing Network of Ottawa o Centralized Housing Registry of Ottawa In an effort to explore how clients in the crisis bed program (and more broadly clients of the crisis team), can be given priority access to appropriate housing options. That, as part of partner presentations to key housing partners, explore partnership opportunities, particularly in the context of upcoming capital RFPs expected to be issued by the City of Ottawa, to identify how future capital builds might incorporate a physical space to site the majority of the crisis beds in Ottawa. That TOH move immediately to submit a proposal to the LHIN, in partnership with key partners serving youth and young adults with mental health needs, to pilot a crisis bed site for youth and young adults. While this site would be located in the City of Ottawa, it would be accessible to youth and young adults throughout Champlain, and proposal planning should actively engage regional partners in how best to address transportation requirements, including exploring how this could be supported through a youth employment initiative. The youth and young adults crisis bed pilot should incorporate peer support, partner agency staff, and specifically target youth and young adults aged The Ottawa Hospital Crisis Bed Program Program Review September 2014

6 Crisis Bed Location: Short, Medium and Longer Term Planning That, on an interim basis, the crisis bed program be reduced to no more than three providers including 2 beds at Ottawa Inner City Health, 6-8 beds at Rothwell Heights retirement residence, and 2 at the YMCA. Remaining funding will be used for hotels or motels on an as-needed basis. Other existing contracted providers of beds will be provided with the requisite three months notice for termination of the contracts by January 31, That the crisis bed program, in its movement towards reducing the number of locations, and incorporating hotel/motel options, define client profiles and needs most appropriate for each of the bed locations, reflecting a continuum of bedded crisis support options for a continuum of client needs. Beginning in the Fall 2014, negotiations will begin with the Youth Services Bureau to establish their potential to provide space for 2 beds for youth and young adults from the City of Ottawa and an additional 2 beds for residents from other areas of the Champlain LHIN area In Winter 2014, that TOH initiate a Request for Proposal process to secure a single site for 6-10 beds (assuming that 2 beds will be retained at Inner City Health, and 2 beds will be located at a Youth Services Bureau site). That the longer term goal will be to actively pursue a facility to locate all of the beds (discussed in further sections). That, over the next fiscal year, a proposal be developed for a single site for mental health crisis beds in Ottawa, incorporating physical plant requirements, options around co-locating staff from multiple agencies, and integration of peer support. Medication Supply and Administration That TOH review policies related to provision of medication supply, specifically as this relates to clients coming through the hospital and being admitted to an Ottawa crisis bed, to ensure medication is packaged in ways that best meet the needs of the client and the program. Currently, discussions are underway to provide medication in bubble packs which is the ideal option. That the Mobile Crisis Team specifically identify which client profiles require assistance with medication administration and which don t, particularly given that this can dictate the type of crisis bed they need in terms of level of supervision. This is consistent with a core value of the crisis bed program (and crisis response in general) to provide the least intrusive approach when working with people in crisis. Evaluation That the Mobile Crisis Team update its evaluation plan to ensure the following outcome indicators and target standards are incorporated in data collection and service user satisfaction surveys, and that mechanisms are in place to assess staff satisfaction. A high-level roadmap has been included to outline next steps for The Ottawa Hospital s consideration. 6 The Ottawa Hospital Crisis Bed Program Program Review September 2014

7 Project Background History of the Crisis Bed Program In 2005, The Ottawa Hospital was provided with funding to support creation of a crisis bed program within the City of Ottawa, and to provide funding to other areas within Champlain to support implementation of crisis beds in those local areas (Renfrew County; Stormont, Dundas & Glengarry; and the United Counties of Prescott- Russell). Essentially, crisis beds are considered a community alternative to inpatient hospitalization. In each area, access to the crisis beds is through local Mobile Crisis Teams. At the time of inception, due to funding constraints, the Ottawa Mobile Crisis Team (a program of TOH) contracted with service providers who already had housing or treatment facilities providing 24/7 staffing for the beds, with daily or almost daily support from OMCT staff. As funding has increased, the model of operation has remained largely unchanged, and TOH contracts with shelters, addictions service providers, and retirement homes for the 11 beds now in operation. TOH pays a per-diem fee to these agencies and they, in turn, provide a private room in their facility. In March 2014, The Ottawa Hospital undertook a review how the current crisis bed program is operating, and how resources might be redeveloped to better fit the needs of current and future clients. In addition, clinical staff from The Ottawa Hospital s Mobile Crisis Team provide mobile support to clients using these beds. This review also provided an opportunity to understand how other areas within Champlain are currently operating their crisis beds programs. Review Activities The report and recommendations were informed by the following activities: Conduct interviews and/or focus groups with clients and family members who have used, or chosen not to use, the crisis bed program Engage with content experts nationally and internationally to review existing practices in the context of evidence-based practices Conduct interviews and/or focus groups with current bed providers in the City of Ottawa and the mobile crisis team to assess current status, current practices, challenges and opportunities Identify opportunities to liaise and link with other programs or initiatives for specific population groups e.g. transition-aged youth Liaise with other crisis bed programs operating within the Champlain LHIN through key informant interviews to assess current status and practices Articulate the challenges and opportunities related to the residential crisis bed program. Specific issues to consider include: o Physical structure (congregate versus dispersed models), o Crisis bed functions and target population, o Skill mix required to support people using crisis beds, o Involvement/engagement of peer support and family peer support o Alignment opportunities with emergency department and hospital discharge planners (including communication and referral processes) 7 The Ottawa Hospital Crisis Bed Program Program Review September 2014

8 Review Process This report summarizes findings from: Two client and family focus groups were undertaken with fifteen participants A meeting with the Family Advisory Committee of the Addictions and Mental Health Network Two meetings with Ottawa Mobile Crisis Team staff members Key informant interviews with crisis bed programs within Champlain A literature scan of existing / better practices in community crisis bed programs Liaison with content experts in other jurisdictions on key programs to profile and for assistance in client and family focus groups Robyn Priest (former lead investigator, Mental Health Commission of Canada) Fran Sylvestri (Executive Director, International Initiative for Mental Health Leadership) Steve Lurie (Executive Director, CMHA Toronto) Marion Wright (Director of Clinical Services, Frontenac Community Mental Health and Addictions Services; Accreditations Canada lead investigator) This report is structured to incorporate better practices, issues and recommendations throughout the report, with a summary roadmap provided in conclusion. Context Making It Happen Crisis response systems are one component of first line services, as defined by the MOHLTC in Making It Happen (the mental health policy framework): Prevention, assessment and treatment by front line health care providers this includes general practitioners, mental health services, social services, hospital emergency services and hospital primary care clinics; Priority population for mental health reform is people with severe mental illness (SMI). First line emergency crisis services must be accessible to all people with symptoms of mental illness; Services include information and referral, crisis telephone lines, mobile crisis teams, Schedule 1 hospital emergency services, holding/safe beds, primary care physicians, mental health counselling, community health centres, and health service organizations. Local planning initiatives (Champlain District Mental Health Implementation Task Force, and, more recently, the regional three year mental health and addictions plan) draw a distinction across two types of beds: Respite beds: community-based beds that provide people with respite from their current living situation, or provide respite for caregivers, Community-based crisis beds: a community-based option where beds are focused on short-term crisis resolution and are not considered a placement for extended observation and assessment. This definition is consistent with that provided by the Ministry of Health & Long-Term Care. 8 The Ottawa Hospital Crisis Bed Program Program Review September 2014

9 The differentiation between these two types of beds is based on the person s needs, a risk assessment, and the core functions of the community crisis beds. The Champlain District Crisis System The crisis bed program sits within a broader crisis system with the Champlain region. More than ten years ago, the service providers funded to provide crisis services across the Champlain District 1 committed to working together to put in place a District-wide bilingual mental health crisis telephone response capability and, in their respective geographic areas, a local assessment and intervention response capability (including a mobile response). The Champlain District-wide mental health crisis line was initiated in July To support the development and on-going operations of the integrated mental health crisis services system, the providers of mental health crisis services in the Champlain District formed a formal Management Committee. Through this structure the providers have set up a collaborative and supportive systems planning process to finalize service agreements; share information and resources; ensure on-going monitoring for quality improvements; and develop and implement an evaluation framework. Recommendation: That the Management Committee incorporate specific objectives relating to crisis bed provision across the region, including identifying opportunities for consistency in inclusion criteria, regional reporting on utilization and issues, and ongoing identification of capacity issues and needs. What follows is a brief description of the three core service components currently provided through crisis funding: the district-wide tier I mental health crisis line (tier I), the local mobile crisis teams (tier II), and the existing crisis bed constellation. Mental Health Crisis Line (Tier I) This Tier 1 line is a collaborative initiative across the Champlain District, including partners from the City of Ottawa (The Ottawa Hospital), and the counties of Renfrew (Pembroke General Hospital), Stormont-Dundas- Glengarry (Cornwall Community Hospital) and Prescott-Russell (Hawkesbury General Hospital). A partnership arrangement, through a formal service agreement, was entered into by all four mental health crisis services providers across the district with the Distress Centre of Ottawa. The total annual funding of $240,000 is made up of equal contributions of $50,000 by each of the three providers outside of Ottawa and a contribution of $90,000 by the Ottawa service. Key characteristics of the service include: The first point of public access to the mental health crisis response system. Serves people 16 years of age and over. Provides a single, district-wide, toll free, bilingual telephone line available 24 hours/7 days a week. Staffed by trained volunteers, supported by professional staff. 1 City of Ottawa, Renfrew County, United Counties of Stormont, Dundas & Glengarry and the United Counties of Prescott- Russell. 9 The Ottawa Hospital Crisis Bed Program Program Review September 2014

10 Provides screening, assessment, referrals, support in a crisis, suicide intervention and transfer to the Mobile Crisis Team or to emergency services when advisable. Access to Service - Public Access o Individuals, families or concerned friends can call the Mental Health Crisis Line at or toll free The volunteer will offer support and, if required, can make a direct transfer to the local Mobile Crisis Team. Local Mobile Crisis Teams (Tier II) A crisis team is operated by each of the partners in their respective geographic area. Mobile Crisis Teams work closely with hospital emergency rooms, community mental health and addictions service providers, psychiatrists, Mental Health Court and police to ensure a safe and comprehensive response. Services include crisis intervention, assessment, consultation, and links to community supports in a least intrusive approach to enable individuals in crisis to remain in their own environment. Consultation and advice can be provided to family members. Short-term follow-up and support can be provided for certain cases to help resolve the crisis. The Mobile Crisis Teams are composed of Crisis Counsellors, Registered Nurses and/or Social Workers. Access to Service - Professional Access o Professionals in the community including agencies, doctors, police, social workers, nurses and others are provided with a direct contact number to the Mobile Crisis Teams. Crisis Beds First funded in 2004/05 by the Ministry of Health (through the Service Enhancement funding initiative), crisis beds are operated in each geographic area, with TOH flowing funding to each of the providers in local areas. Community crisis beds provide an alternative to hospitalization for people experiencing mental health crisis, including a focus on keeping people out of the criminal justice system. Services include crisis intervention, monitoring and assessment, and linking people to community supports. Generally, beds are provided through an agreement with organizations who already have staff available on a 24/7 basis, and crisis team staff regularly visit clients using the crisis beds. There is a strong emphasis on diversion from emergency rooms Access to Service Mobile Crisis Teams o Crisis teams in each local area are the central point of access to local crisis beds although they work closely with emergency room staff in local hospitals when clients present in hospital settings. The Ottawa Hospital Crisis Bed Program The Ottawa Hospital Mobile Crisis Team has 11 community crisis beds at 6 different agencies located throughout Ottawa. These crisis beds are a voluntary, community based alternative for people experiencing mental health crises who do not require an acute inpatient hospitalization, but who would benefit from access to temporary housing and support. The community crisis bed program provides an opportunity for an individual to initiate 10 The Ottawa Hospital Crisis Bed Program Program Review September 2014

11 steps to resolve the current crisis through problem-solving, symptom stabilization, and reconnection to community supports. Mobile Crisis Team staff meet daily with the client in the community crisis bed to assess mental status, medication response, symptom stabilization, and to begin a holistic approach to crisis resolution through connection to formal and informal supports, and enhancement of coping skills. The target length of stay is 5 days. Staff within the community agencies provide clients with assistance in activities of daily living such as meal preparation, laundry, and, often, medication facilitation. Referrals for the community crisis beds are made through the Mobile Crisis Team. The Mobile Crisis Team will assess the client and respond to the referral source regarding whether the client has been accepted to the community crisis bed program. Admission Criteria Clients must be 16 years of age and older for most crisis bed residences (18 years old to stay at specific agencies) Reside within the City of Ottawa Have serious mental health issues and are experiencing a mental health crisis (including psychosocial crises) Do not require inpatient admission** based on risk assessment (no imminent risk of suicidal, assaultive, selfharm or destructive behaviours) AND are willing to be voluntarily admitted to the crisis beds Are in stable physical health and have the ability to self-care for basic physical and personal needs Are able to administer own medications Willing to abstain from alcohol and/or substance use while in the crisis bed Exclusion Criteria Risk assessment indicates that an inpatient admission or detox facility would be most appropriate treatment choice There is a significant history of violent or assaultive behaviour Client does not consent to admission to the beds Treatment recommendations require close medical or psychiatric supervision Are likely to wander and are incapable of returning to the Community Crisis Beds independently Are already living in a 24/7 mental health or long-term care supported bed Present with problems which are primarily caused by a developmental delay condition or dementia Primary crisis is housing related no mental health concerns 11 The Ottawa Hospital Crisis Bed Program Program Review September 2014

12 System Context Deinstitutionalization and Hospital Diversion Consistent with a global movement towards deinstitutionalization of people living with serious mental illness, there have been significant community investments in community-based mental health services in Ontario over the last fifteen years which, at least in part, have been intended to coincide with closure of provincial psychiatric hospital beds. Community mental health providers first began receiving government funding in 1976: to contextualize the significant increases, between fiscal years 2001 and fiscal years 2007, funding to community mental health services in Ontario increased from $390 million to $647 million 2. By 2009, funding was at about $683 million. In 2011, Canada had one of the smallest numbers of psychiatric care beds per 100,000 population (33 beds/100,000 population) among all OECD countries 3 : the cautionary note, then, is that community-based services must correspondingly meet the needs of people in the community, however this has not been the experience of clients and family members. Indeed, the 2008 Auditor General s Report, while acknowledging that the Ministry of Health had nearly reached its interim goal of 35 psychiatric beds/100,000 population, noted that the system was still far from its target of investing 60% of mental health spending on community Based services. As of fiscal year 2006, the MOH spent about $39 on community-based services for every $61 spent on institutional services. Other findings included the dearth of availability of supportive housing (with wait times ranging from one year to six years across the province) and significant wait times for other community-based mental health services (averaging 180 days, with a range of eight weeks to a year or more for services). In a 2010 follow-up report by the Auditor General, the MOH noted it would be undertaking a review of short-term crisis beds and establishing standards for crisis beds in Ontario 4. As of the date of this report, no such review has been published. Ultimately, these system pressures and lack of system capacity have a cascading effect, leading to increased utilization of emergency rooms, and inpatient services. A central goal of the Champlain LHIN is to decrease utilization of emergency rooms and inpatient services where other appropriate alternatives are available, such as the community crisis beds. Most recently, the LHIN supported the development of a three-year community action plan for mental health and addictions services (Connecting the Circle). In particular, the value stream mapping exercise emphasized the need for integrated access to community crisis beds, as well as the need for respite bed options (which have been recommended but not funded through multiple system planning exercises) Annual Report of the Office of the Auditor General of Ontario, p Australia at the forefront of mental health care innovation but should remain attentive to population needs, says OECD Auditor General Follow-up Report to 2008 Annual Report The Ottawa Hospital Crisis Bed Program Program Review September 2014

13 Current approaches in crisis bed provision in Champlain Partners reflected on a number of issues related to crisis bed provision outside of the City of Ottawa, including: Youth and young adults are one of the most challenging groups: they can require higher levels of supervision because of their age and should be kept separate from older clients where possible Length of stay is very challenging to meet, and this primarily relates to housing issues clients are experiencing A growing issue are co-occurring health issues clients have, and how best to ensure those are met: although all areas use retirement homes, some homes won t accept clients under the age of 65 Tracking admissions and other service-level data can be complicated: where agencies are using CRMS, utilization of the crisis service versus the beds isn t tracked separately The following table provides an overview of how crisis beds are organized across Champlain: The Ottawa Hospital is the transfer payment agency for all funding for the crisis beds in Champlain. Funding for the beds is for the purchase of the beds themselves and does not include additional costs related to administration, transportation, staffing, and physic an consultation costs. Recommendation: That crisis bed providers use existing collaboration mechanisms for the regional crisis line and crisis teams to articulate common standards, guidelines or procedures for crisis beds across Champlain, including target length of stay, utilization of peer support, medication management, regional tracking of bed utilization and access processes, and other issues as identified 13 The Ottawa Hospital Crisis Bed Program Program Review September 2014

14 Local Area Number of Beds Physical structure / bed location Funding Support Levels Target Length of Stay Ottawa 11 In 6 locations: $276,960 for Crisis team meets 3-7 days but can be Rothwell Heights Retirement Home bed purchase daily with clients extended (in (4 beds, M or F) FTE (sometimes less particular for Ottawa Inner City Health (social work depending on housing-related Salvation Army (2 M) and RN) client need) issues) The Oaks (2 beds, M or F) equivalent to YMCA/YWCA Shenkman Residence 12 hours (1 M bed and 1 F bed) coverage/day Alexander House (1 bed, M or F) Renfrew County 3 In multiple locations (pay based on bed use): primarily using a hotel and motel, but have some arrangements with Carefor in Pembroke and Renfrew Victoria Hospital for their elder abuse program for people that require additional support Additionally, have an extra bedroom in their Semi- Independent Living home through Homes for Special Care (total of 3 beds) which is used occasionally $36,500 Crisis team may not go out on a daily basis to clients in beds depends on level of need, also try to encourage clients to implement their plan themselves Range of 3 days week is the target can extend for as long as a month (usually due to housing issues) Generally average 25 admissions annually but significant range (e.g. last year was 40+) Partnerships Noted organizations Psychiatric Emergency Service TOH Receive referrals from police as well as other community partners (including assertive community treatment teams and Canadian Mental Health Association), shelters Carefor Renfrew Victoria Elder Abuse Program Crisis team has agreement in place for all five hospitals within the County to go onsite to meet with people Receive referrals from police as well Prescott-Russell 2-3 In multiple locations (pay based on bed use except for Residence McDonald in Van Kleek Hill where there is a contract for annual utilization) Will use another residence for a second bed capacity if needed, and $36,500 Crisis team may not go out on a daily basis to clients in beds depends on level of need, availability of Maximum 10 days sometimes extends by 2-3 days to ensure person has place to go to Minimum 40 admissions annually Residence McDonald Crisis beds/crisis team are a service of the Hawkesbury General Hospital Receive referrals from multiple sources 14 The Ottawa Hospital Crisis Bed Program Program Review September 2014

15 Local Area Stormont, Dundas and Glengarry Number of Beds Physical structure / bed location Funding Support Levels Target Length of Stay motel very occasionally resources also use phone calls as a method of staying in contact 3 In multiple locations (pay based on $36,500 Crisis team does Maximum 5 days bed use) in Cornwall follow up with Motel, residential home, residential clients in beds retirement home relationship with Good working relationships with other services as management at each of the well locations Partnerships Crisis team, ACTT, Withdrawal Management Services and ER have access to beds 15 The Ottawa Hospital Crisis Bed Program Program Review September 2014

16 Challenges and Opportunities: Ottawa Crisis Bed Program Admission and Exclusion Criteria For a variety of reasons, people are sometimes admitted to the crisis bed program who don t fit within the existing inclusion criteria. These reasons include: Recognition that the current inclusion/exclusion criteria prevent appropriate admissions and are inconsistent with better practices: for example, o o Clients who are admitted through the Mental health Court often have some history of violence Adoption of a more harm reduction centred approach which recognizes that there are clients who use substances, but that substance use is only an issue if it is obstructing progress with respect to the client s treatment plan Current pressures in emergency and inpatient services, with pressure from emergency room staff to admit someone in order to prevent a hospital admission, Person-centred planning/clinical judgement/lack of housing options: staff recognize that there are some situations where a crisis bed admission is necessary to prevent continued escalation of the pressures the person is facing predominantly, these can be attributed to housing crises, with the team recognizing that without pre-emptive intervention, the person will eventually experience escalating mental health issues Keeping strictly to inclusion criteria (as they currently stand) can substantively decrease utilization of the beds, and there is an acknowledgement that a community alternative to hospitalization and/or escalating crisis is necessary. For this reason, Recommendations: In the context of a broader discussion with crisis bed partners, that current inclusion and exclusion criteria be reviewed and updated to reflect the following considerations and current practices, at a minimum That clients presenting in emergency or through Mental Health Court be considered high priority for admission to a crisis bed, That ability to administer their own medications be removed from the inclusion criteria, That willingness to abstain from substance use be removed from the inclusion criteria, That a significant history of violent or assaultive behaviour be removed from the exclusion criteria That exclusion criteria remove reference to developmental delay and housing-related crises This type of revision to inclusion and exclusion criteria needs to reflect more on behaviour and capacity related issues of the person. That emergency department staff receive training on inclusion/exclusion criteria and procedures are developed to articulate the referral process when a client presents at the emergency department. That TOH engage with leaders in the dual diagnosis (mental health and developmental delay) field to outline a process that best meets the needs of people who are experiencing a mental health crisis, but also having varying degrees of developmental disabilities. the lack of respite bed options within the community can lead to admissions which are more related to current living situation and/or pressures as opposed to meeting a rigorous definition of crisis. 16 The Ottawa Hospital Crisis Bed Program Program Review September 2014

17 Quotes from Clients and Family: We don t have access to respite like they do in dementia part of the fatigue is, you try to get in and you re disappointed. I much prefer to be told up-front, I m telling you, it s not a good match with what we do. It was a very smooth transition it was exactly what I needed. There are doors closed all over the place [in the mental health system] this is a door that needs to be open. The Crisis Team they saved my life. When I first walked in the place, I felt more depressed, but people were good to me and so what it looked like physically wasn t as important. The doctor told me there was an alternative I was extremely impressed by how efficient it was. Location issues Almost universally, mobile crisis team staff, clients and families have identified issues with the current locations of the crisis beds. Consistent with feedback from crisis bed programs across Champlain, Ottawa staff identified the challenges associated with youth and young adults, clients with middle or higher incomes, and clients with physical health needs. The current locations of the crisis beds are primarily retirement residence or shelter-based. While this provides some potential clients with an appropriate environment (such as older clients, as well as street-involved clients), they are mostly ineffective and inappropriate as a setting for younger clients, or clients who have middle or higher incomes. Quotes from Clients and Family: The place I m in right now it s not physically accessible. Currently, these client groups are most often placed at the beds located at the YMCA, however, this is a location that has little ability for staff on-site to provide medication monitoring and supervision. Multiple locations increase staff time spent in travel and liaison with multiple partners. It s clear that the number of locations needs to be reduced to increase efficiency, and also to identify additional options that better meet the needs of youth and young adults. For me, it was really a respite. And it was absolutely incredible follow-up. If I called them today, they would take my call. But when I first walked into the place, I wanted to leave. 17 The Ottawa Hospital Crisis Bed Program Program Review September 2014

18 Recommendation: 1) That, on an interim basis, the crisis bed program be reduced to no more than three providers including 2 beds at Ottawa Inner City Health, 6-8 beds at Rothwell Heights retirement residence, and 2 at the YMCA. Remaining funding will be used for hotels or motels on an as-needed basis. Other existing contracted providers of beds will be provided with the requisite three months notice for termination of the contracts by January 31, ) Beginning in the Fall 2014, negotiations will begin with the Youth Services Bureau to establish their potential to provide space for 2 beds for youth and young adults from the City of Ottawa and an additional 2 beds for residents from other areas of the Champlain LHIN area 3) In Winter 2014, that TOH initiate a Request for Proposal process to secure a single site for 6-10 beds (assuming that 2 beds will be retained at Inner City Health, and 2 beds will be located at a Youth Services Bureau site). 4) That the longer term goal will be to actively pursue a facility to locate all of the beds (discussed in further sections). In implementing these recommendations, The Ottawa Hospital will also review the considerations for the community crisis beds, as developed by Agnew Peckam as part of the functional program planning process. These considerations have been included below: Organization of the beds - How should the beds be organized? Should they be consolidated in one location or several locations? If the latter, how many beds should be in each location to ensure a critical mass. Location of the beds - Where should the beds be located to provide best access by clients? Do the beds need to be in proximity to the TOH Mobile Crisis Team? If the beds are not in a single location, should they be in close proximity or at a distance from each other? Delivery of the services - Should the beds be operated by one or multiple providers? How will quality standards be maintained? Quotes from Clients and Family: Once I was in the bed, it was very good care I probably should have gone to a hospital and gotten help earlier. Sometimes you need a place to get away to a place that s away from the stressors in your life, where you have someone to talk to. But it should feel nice when you go there you shouldn t feel like a second class citizen because you have a mental illness. It was a godsend to know there would be someone that I was going to be able to talk to and it was clear they really cared. Detailed criteria for the physical location (s), have been included in Appendix B. 18 The Ottawa Hospital Crisis Bed Program Program Review September 2014

19 People with mental health and addictions issues Additionally, crisis team staff spoke about their concerns relating to clients requiring detox services related to substance use problems. In theory, crisis beds are not to admit clients with these needs: the practical reality of pressures at the hospital level has sometimes impacted the application of this exclusion criteria. Recommendation: That TOH engage with Withdrawal Management Services to effect a priority system for people presenting to the Emergency Room requiring WMS so as to ensure that these clients are not streamed to a crisis bed at an inappropriate time in their individual process. This engagement should include representation from the Champlain LHIN and should consider the following: priority access, communications among key partners (hospital emergency staff, OMCT and WMS staff), and collaborative treatment planning for people requiring and desiring both withdrawal management and crisis services. Medication supply, administration, and supervision I find there are just always problems with medications and dosages (mobile crisis team staff) A number of crisis team staff identified the lack of It is unclear the extent to which medication administration is required for all clients and, given that most clients are being discharged to a home environment and will be taking their own medications, careful consideration is needed to identify which clients require close medication supervision (or assistance with administration) and which do not. This forms one part of a broader discussion about the philosophy of the crisis beds. Recommendation: That TOH review policies related to provision of medication supply, specifically as this relates to clients coming through the hospital and being admitted to an Ottawa crisis bed, to ensure medication is packaged in ways that best meet the needs of the client and the program. Currently, discussions are underway to provide medication in bubble packs which is the ideal option. Recommendation: That the Mobile Crisis Team specifically identify which client profiles require assistance with medication administration and which don t, particularly given that this can dictate the type of crisis bed they need in terms of level of supervision. This is consistent with a core value of the crisis bed program (and crisis response in general) to provide the least intrusive approach when working with people in crisis. Length of Stay When the crisis bed program was in its first planning stage ten years ago, partners clearly noted that success of these beds is dependent on appropriate and timely discharge with appropriate services in place: Partnerships are essential to effective implementation. Universally, programs across Champlain 19 The Ottawa Hospital Crisis Bed Program Program Review September 2014

20 have identified issues relating to meeting a target length of stay of around five days to being tremendously challenging to meet, particularly in relation to the availability of housing options in the community. Recommendation: That the Mobile Crisis Team prepare a present a report on current issues with respect to housing and support options of crisis bed clients to : Supportive Housing Network of Ottawa Social Housing Network of Ottawa Centralized Housing Registry of Ottawa In an effort to explore how clients in the crisis bed program (and more broadly clients of the crisis team), can be given priority access to appropriate housing options. That the target length of stay for crisis beds be articulated in collaboration with other crisis bed providers within the Champlain LHIN, and in collaboration with LHIN staff. Linkages and Partnerships One of the benefits of the multiple locations of the crisis beds has been the opportunity for mobile crisis team staff to build relationships with organizations across the city. At the same time, staff, clients and families talked about the potential of creating new partnerships that would enhance people s experiences when they re using the crisis beds, specifically in the area of programming and peer support. Crisis team staff also discussed the nature of the needs of clients that they see including social isolation, and a tendency to have had a lengthy involvement with the mental health system. They expressed concern about where their role ends because the needs of the clients can be so complex, that it can be difficult to disengage. While there is a role for system navigation or coordination of referrals within the mobile crisis team, and particularly in the context of working to address the client s issues while they re in the crisis beds, the team is keenly aware that they do not have an ongoing role with clients. Quotes from Mobile Crisis Team Staff: It s hard to stop, people need income, they need housing, it s not good enough to just find them a rooming house.there have been miracles accomplished. We get the people who have been hiding, living unimaginable lives, for years Recommendation: There is a need to look at the development or enhancement of relationships with particular organizations. At a minimum, these should include: Housing providers as noted previously, it s crucial that key networks and the centralized housing registry be aware of the crisis bed program, and that high priority be given to housing people in the crisis beds. CMHA Ottawa while there is an existing relationship with the Canadian Mental Health Association, the recent investment in Transitional Coordinators, targeting people at risk for use of emergency and inpatient services and often with multiple and complex needs, provides an opportunity to 20 The Ottawa Hospital Crisis Bed Program Program Review September 2014

21 engage with CMHA on how these new staff members could be involved in matching up with clients who are frequent users of crisis, emergency and hospital services. Psychiatric Survivors of Ottawa there is a significant role that peer support can play when people are experiencing crisis and after. In addition to providing almost daily peer support, social or recreational opportunities, PSO has more recently implemented the Recovery Connections peer support and family peer support team within two hospitals within Ottawa, and is in the process of implementing the program at TOH as well, with an emphasis on clients transitioning back to community. There may be opportunities to Quotes from Clients and Family: I was in a really bad place but no one ever offered a crisis bed option. Maybe they didn t know? I do think education about the mobile crisis team is really important. My family doctor told me about the bed. provide a targeted approach to clients who are frequent users of crisis, emergency and hospital services and, at a minimum, to review how existing peer support groups could be made accessible to people using crisis beds. This exercise needs to focus on leveraging organizations areas of expertise: for example, in a 2012 review of various models of peer support in the United States, researchers found that about 8% of peer support groups or organizations provided respite care, 49% worked with people to secure services they wanted/needed, 34% engaged with people in their housing difficulties, in addition to provision of drop-in centres (34%), mentoring/matching (38%), telephone support (68%) and assisting people in getting jobs (21%) 5. An extensive from the U.S. Government s Substance Abuse and Mental Health Services Administration (SAMHSA) departmental review 6 on consumer-operated programs found that they can and do provide concrete services such as safe shelters, and assistance with other basic needs, such as housing, employment, and education. The programs also may provide crisis response services, links to resources, social and recreational opportunities, information/education, and outreach. Capacity and Utilization Quotes from Mobile Crisis Team Staff: The longer we have them in the bed, the better the chance they won t be back. I know I did a better job last year, because there were fewer people with really high needs. In general, this region has applied planning benchmarks for crisis beds based on common practices of 2 crisis beds/35 inpatient beds (equivalent to 1 bed/83,000 population). 7 This isn t inconsistent with more recent planning and benchmarking exercises, however, shouldn t be viewed in isolation of the need for respite beds, which are a crucial option for people experiencing different stressors in their lives 5 National estimates for mental health, mutual support groups, self-help organizations and consumer-operated services, 2012, Goldstrom et al., 6 U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. Consumer-operated Services: The Evidence, 2008, DVD/TheEvidence-COSP.pdf 7 See Champlain District Mental Health Implementation Task Force, First Line Services and Housing Reports, The Ottawa Hospital Crisis Bed Program Program Review September 2014